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A Knowledge for Practice 2 (BN605) > Wound Care > Flashcards

Wound Care Flashcards

1
Q

What are the four stages to wound healing?

A

Hemostasis
Inflammatory Phase
Proliferative Phase
Maturation Phase

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2
Q

What is the Hemostasis phase of wound healing?

A

Hemostasis
* Immediate; 0 - 2 days
* Thrombin converts to fibrinogen
* Coagulation from dilated vessels

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3
Q

What is the Inflammatory phase of wound healing?

A

The body’s protective response to injury
* 2 to 4 days, pain, redness, heat, swelling and loss of function at the site of injury
* If > 48-72 hours, look for evidence of new or ongoing tissue damage or infection

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4
Q

What is the Proliferative Phase of wound healing?

A
  • 4 to 21 days in length
  • Rebuilding tissue; Filling by granulation, contracting the wound through contraction and converting the wound through epithelialization
  • Includes remodeling; Strengthens
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5
Q

What is the Maturation Phase of wound healing?

A

Maturation Phase
* up to 2 years Wound gains tensile strength

  • wound appears healed but Collagen production and reorganization will be ongoing for years.
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6
Q

What is Palliative Wounds?

A

Not going to heal = “palliative wounds”
Patient and wound related factors mean there is no potential for
healing

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7
Q

What are the Palliative Wound Care Principles?

A

Key Principles
* Prevent wound development / deterioration
* Correct / treat underlying cause
* Control wound related symptoms
* Utilise patient self-assessment
* Provide psychosocial support
* Promote independence
* Improve quality of life
* It is NOT an excuse for poor wound care

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8
Q

What are issues with hard to heal wounds?

A

Living with a Hard to Heal Wound
* Pain, exudate and malodour
* Anxiety, depression, self-neglect
* Loss of self-esteem
* Loss of control
* Social isolation
* Poor sleep
* Role functioning (work, financial, mobility)
* Inconvenience (dressings, clinic etc)

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9
Q

What does wound Assessment involve?

A

 Assessment the Whole Person
General condition of the patient
Medical and surgical history
Contributing factors that may impair healing
Pain
Wound Assessment and Plan

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10
Q

What is on wound assessment form? DHB

A

Initial goal
Diagnosis
Factors that may impede healing
Intermittent Goal setting
Discharge planning
Wound measurement

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11
Q

How to measure wounds?

A

Consistent method for measuring longest wound length and widest width

Use Clock face to describe e.g. 9 cm sinus at 12 o’clock

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12
Q

What is probing and how should you do it?

A

The act of using a long instrument to examine a patient’s body

Don’t Use Metal Probes
Use soft tipped Measurement Probes

Probing should be done gently by competent clinician

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13
Q

What are the four kinds of conditions a wound bed can be?

A

Dry eschar/ Black Necrosis
Yellow slough
Granulation tissue
Epithelising

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14
Q

What is yellow slough?

A

Yellow slough you don’t want. Yellow slough is waste material that the body produces. Its not healthy.

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14
Q

What is Granulation tissue?

A

Granulation tissue is a type of new connective tissue that forms in wounds as they heal. It is an important component in the wound healing process

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15
Q

What is necrotic tissue?

A

Necrotic tissue is dead or devitalised non-viable tissue which impedes wound healing. Can delay wound healing.

16
Q

What is Epithelising wound tissue?

A

The process by which the epidermal cells regenerate and migrate to cover a wound is called “epithelialization.”

Epithelializing wound tissue is the process of repairing a wound by regenerating and migrating epidermal cells to cover the wound. It’s the final stage of wound healing and occurs during the proliferative phase.

17
Q

What is Exudate Level?

A

Exudate level refers to the amount of fluid that drains from a wound during the healing process

18
Q

When assessing Exudate Level, what should you include?

A
  • Condition of the current dressing
  • Frequency of dressing
  • Dry dressing indicates low exudate
    levels
  • Leaking dressing indicates higher level

Moist- little fluid on dressing
Wet- Small amounts of fluid on wound dressing marked
Saturated- Excess fluid on wound

19
Q

What are the kinds of exudate Type and Level

A

Exudate Type consistency and odour

Serous (clear, straw colour)

Purulent (cream or green)

Haemopurulent (red, brown) may
indicate infection

Malodour - may indicate infection
or fistula

20
Q

What are kinds of Pain Treatment for wound dressing?

A

Coordinate care with pain medication administration
Premedication – Short acting opioid/booster dose
Entonox gas
Nerve block
Use “Time out”
Keep wound covered using a non-adherent dressing
Reduce frequency of dressing
Consider using topical opioids/anaesthetics
Non pharmacological strategies

21
Q

What are treatment objectives for wounds?

A

Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue

22
Q

What is the purpose of wound cleansing?

A

To remove
 Debris (e.g. Surface contaminants, dressing remnants)
 Desvitalizad tissue
 Microorganisms
 Exudate

23
Q

In wound care what do you do with dead space?

A

Dead space must be filled with dressing
material to ensure that wound closure is delayed until the space has been replaced with granulation tissue:
* Cavity
* Undermined tissue
* Tracts
* Make sure you can get it out in one piece!

24
Q

What are some wound care principles?

A

If there is no blood supply keep it dry (unless advised otherwise).

Take care of the peri wound area

Keep it Simple

Stick to your Wound Product Guide & Company Guidelines

25
Q

How to keep the peri wound healthy?

A

Keep Surrounding Skin Healthy and Intact
 Skin Barrier Products
Use Adhesive Remover
Reduce Pain

26
Q

What are Low or non adherent layer wound dressing?

A
  • Low adherent wound contact layer
  • Water repellent ointment i.e. paraffin
  • Silicone dressing (expensive)
  • Can have antiseptic in it (Bactigras)
  • Less traumatic to remove
  • For wounds with superficial skin loss
  • Need secondary dressing
27
Q

What are Polyurethane Films?

A

Polyurethane (PU) films are a type of wound dressing that can be used to protect wounds and promote healing

  • Waterproof
  • Gas vapor permeable
  • Flexible, conformable
  • Protect vulnerable tissue
  • Transparent, allowing easy monitoring
  • Impermeable to micro-organisms
28
Q

What are Island dressings?

A

Properties:
* primary dressing on dry or lightly
exuding wounds
* Barrier and non barrier available
Wound types:
* Post op, low exudate
How to use, when to change:
* PRN – depends on wound and protocols post. Op.
Contraindications:
* Moderate to highly exudating
wounds

29
Q

What are Alginates (Seaweed) dressings?

A

Made from brown seaweed that can be used on wounds to absorb fluid and promote healing

  • Combine with wound exudate to form a hydrophilic gel.
  • Easily removed from wound as non adherent.
    *Hemostatic properties.
  • Require secondary dressing.

Ask ‘what do I want the dressing to
do…?’
Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue

30
Q

What are Gelling Fiber dressings?

A
  • Made from hydrofiber is a soft,
    sterile, non-woven pad or ribbon
    dressing)
  • conformable and highly absorbent
    dressing
  • absorbs wound fluid and creates a
    soft gel which maintains a moist
    environment.
31
Q

What are wound dressing foams?

A

Foams
* Moderate to heavy absorbency
*Insulating
* Moist interface
*Non-adherent
* When do you change a foam dressing?

*Mepilex *Allevyn *Polymen *Polyfoam

32
Q

What are Hydrogels – moisture donating?

A

moisture donating
* Up to 95 % water content
* Re-hydrate necrotic/sloughy tissue
* Aid autolytic debridement
* Provide pain relief
* Minimal absorbency capacity

33
Q

What are Antimicrobials?

A

Iodine, Silver, Honey

34
Q

How to choose a dressing

A

Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue

35
Q

What are some Low Adherent Mesh (no absorbency) dressings

A

Cuticerin

36
Q

What are some Antimicrobial dressings

A

AMD foam non-adhesive

A Knowledge for Practice 2 (BN605) (18 decks)

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